2.0 Analysis 2.1 Introduction The owner/operator was aware that the vessel was very tender when heavily laden with prawn traps. Historically, he had travelled, on occasion, with a larger number of traps on the afterdeck; however, during those times, the stabilizers were often deployed. In this instance, the stabilizers were not deployed because the weather was fine when the vessel left port on 13 April 1994. On 14 April 1994, the weather and sea conditions had deteriorated later in the day, but the decision to deploy the stabilizers was made only seconds before the vessel capsized. A small craft warning was in effect in the area. 2.2 Stability A period of roll is the time, in seconds, for a vessel to roll from one side to the other and return to the original side. The period of roll may be used as a method to approximate a vessel's metacentric height (GM) and initial transverse stability. It is used primarily for vessels up to 24 m in registered length, when it is not practical to carry out an inclining experiment or, as in this case, when an inclining experiment is not required by regulation. According to her rolling characteristics when heavily laden, the LADY DEVINE would appear to have been a tender ship with a small righting moment and reduced freeboard. In this instance, the vessel did not have sufficient transverse stability to withstand the dynamic heeling effects of waves, wind, and water shipped and retained on deck. The south-easterly wind opposing the easterly tidal flow created a steep confused sea. Some of the waves were larger than the others and, when the bulwark was submerged, the shipped seawater flooded the afterdeck, heeled the vessel to starboard, and prevented her from returning to the upright. The side of the vessel, and her wheel-house, the stacked traps, and tarpaulin presented a large surface area to the wind and acted like a large sail. This force, in conjunction with the shipped water which was retained on deck, effectively retarded and subsequently prevented her return to the upright, allowing seawater to downflood into the hull through the open door at the after end of the wheel-house and into the fish hold when the hinged hatch cover became displaced. 2.3 Sea State Waves that are larger than the majority of those present are often encountered. These rogue waves occasionally cause structural damage and sometimes cause vessels to capsize. The sea and tidal conditions combined with the strong wind produced a steep and confused sea. 2.4 Situational Awareness and Information Processing The weather, although fair upon departing Gibsons, B.C., on 13 April 1994, had deteriorated on the afternoon of 14 April. The owner/operator was aware of the changing conditions and, when the vessel was off Port Neville, a strong tide rip and a confused sea were encountered. The owner/operator was aware of the dangers associated with the weather conditions, but he had not decided if he would continue or enter Port Neville and wait for the weather to moderate. Because the vessel proceeded to sea in adverse weather conditions with watertight/weathertight openings not securely shut, there was an apparent lack of appreciation of the dangers associated with a possible ingress of seawater through those openings. 2.5 Crew Decision Making Over the years, fishing has been transformed from an occupation based on traditional knowledge and skill to one based on management skills and entrepreneurial abilities. Fishing, in general, is a high-risk occupation and the traditional attitude of the fishermen is to accept the risk involved[4]. Thus, threats posed by the hostile environment are often downplayed in the initial stages and during the decision-making process, and are responded to only when danger arrives, in some cases, with tragic consequences. Because fishing is physically demanding, the crew sets practices to facilitate operations. These practices, when continued, form habits, and the resultant changes in attitude and perception can inadvertently compromise safety. In this instance, weathertight/watertight accesses were left open at sea, permitting downflooding to occur and progress until the vessel capsized. 3.0 Conclusions 3.1 Findings The vessel's effective after freeboard and transverse stability were markedly reduced due to the large number of prawn traps that were stowed on the afterdeck. This condition was exacerbated by the windage of the traps and tarpaulin, sea conditions, and slack tanks. The door at the after end of the wheel-house and the fish hold hinged hatch cover were left open and unsecured, allowing the downflooding of the vessel which resulted in her capsizing. The owner/operator was aware that a small craft warning was in effect for the area the vessel was to travel, but he chose to continue with the voyage. The deck-hand was sent to deploy the stabilizers but the vessel capsized before he could deploy them. There was insufficient time to retrieve the lifejackets or emergency supplies. 3.2 Causes The effective after freeboard and transverse stability of the LADY DEVINE were markedly reduced due to the number of prawn traps stowed on the afterdeck. The weather deteriorated later in the day and stabilizers were not deployed. The stacked prawn traps and a nylon tarpaulin presented a large surface area to the strong wind and acted like a large sail retarding the vessel's return to the upright. The vessel shipped and retained water on the weather deck, downflooded, and capsized to starboard. Seawater entered the forward under-deck compartments through the open door at the after end of the wheel-house and through the fish hold when the unsecured fish hold hinged hatch cover became displaced. 4.0 Safety Action 4.1 Action Taken 4.1.1 Unsecured Openings Once again, a breach of watertight integrity due to unsecured openings has contributed to a fatal marine accident. In view of the continuing occurrence record of vessels being lost due to unsecured openings, and subsequent to the sinking of the fishing vessels NADINE and CAPE ASPY for similar reasons, the Board recommended that Transport Canada develop and implement measures to ensure that owners, operators and masters of vessels under its jurisdiction have effective training and procedures for securing all exterior and interior openings sufficient to preserve the watertight integrity of the hull for the environmental conditions being encountered (M93-01). Furthermore, on a separate occasion, following the sinking of the fishing vessel NORTHERN OSPREY, the Board recommended that Transport Canada promote awareness among the operators, officers and crews of fishing vessels of the serious consequences associated with leaving access or other watertight doors open at sea (M92-04). As a result, the Canadian Coast Guard (CCG) issued a Ship Safety Bulletin (SSB) urging mariners and operators to keep watertight openings closed at all times except when it is absolutely necessary to open them to gain access to spaces (SSB No. 16/92). Transport Canada also re-issued previous SSB Nos. 1/83 and 4/87 on the same subject. It is also understood that watertight integrity and its effects on vessel stability are being brought to the attention of the industry by the Examiners of Masters, Mates, and Engineers through intensified examination in these areas by the CCG.